- Email: [email protected]
Attenuation of the hypertensive response to tracheal intubation in patients with severe preeclampsia: a UK postal survey
102
Correspondence
it had been used, 155 (50%) would keep it on the same surface. This practice may increase the risk of contaminating the spinal equipment with disinfectant. Of the respondents, 357 (62.4%) always allowed the solution to dry before the procedure and a further 197 (34.4%) usually did. Failure to allow the solution to dry may also increase the risk of contamination of equipment. Use of an introducer needle may reduce the risk of spinal needle contamination. However, contamination is still theoretically possible, either from a retained core of skin within the introducer needle, or whilst the spinal needle is still on the sterile surface. Disinfectant need not be poured into the receptacle whilst it is on the same surface as the spinal equipment. Equally, spraying disinfectant directly onto the patients back enables distance to be kept from the spinal equipment and is equally effective.9,10 Whether pouring or spraying, multi-use containers could potentially become contaminated.11 Devices such as ChloraPrep resolve many of these issues but increase the production of waste and ChloraPrep only comes as 2% chlorhexidine gluconate in 70% isopropyl alcohol. Our survey demonstrates that there are still consultants using suboptimal disinfectants or not using them correctly. An even greater number of consultants are pouring the disinfectant into a receptacle on the same surface as the spinal equipment which may increase the risk of contaminating the equipment with disinfectant. Although the incidence of serious infective and neurotoxic complications remains small, the risks could be reduced by changing these practices. C.L. Bradbury, B. Hale, S. Mather, I. Suri Department of Anaesthetics, Warwick Hospital, Warwick, UK E-mail: [email protected]
References 1. Christie I. Infective meningitis. In: The Royal College of Anaesthetists. NAP 3: major complications of central neuraxial block in the United Kingdom. The Royal College of Anaesthetists; 2009: p. 71–5. 2. Pratt RJ, Pellowe CM, Wilson JA et al. Epic2: national evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 2007;65:S1–S59. 3. Hebl JR. The importance and implications of aseptic techniques during regional anesthesia. Reg Anesth Pain Med 2006;31:311–23. 4. Crowley L, Preston R, Wong A, Book L, Kuzeljevic B. What is the best skin disinfectant solution for labour epidural analgesia? A randomized prospective trial comparing ChloraPrep, DuraPrep, chlorhexidine 0.5% in 70% alcohol. Anesth Analg 2008;106:A3. 5. Cook TM, Fischer B, Bogod D et al. Re: antiseptic solutions for central neuraxial blockade – which concentration of chlorhexidine in alcohol should we use? Br J Anaesth 2009;103:456–7. 6. Fischer B, Damian M. Other nerve and spinal cord injury. In: The Royal College of Anaesthetists. NAP 3: major complications of
7. 8. 9.
10.
11.
central neuraxial block in the United Kingdom. The Royal College of Anaesthetists; 2009, p. 77–83. Angelique Sutcliffe v Aintree Hospitals NHS Trust, EWCA Civ 179, 2008. CareFusion. ChloraPrep (www.chloraprep.co.uk). Robins K, Wilson R, Watkins EJ, Columb MO, Lyons G. Chlorhexidine spray versus single use sachets for skin preparation before regional nerve blockade for elective caesarean section: an effectiveness, time and cost study. Int J Obstet Anesth 2005;14:189–92. Debreceni G, Meggyesi R, Mestyan G. Efficacy of spray disinfection with a 2-propanol and benzalkonium chloride containing solution before epidural catheter insertion – a prospective, randomized, clinical trial. Br J Anaesth 2007;98:131–5. Birnbach DJ, Stein DJ, Murray OMT, Thys DM, Sordillo EM. Povidine iodine and skin disinfection before initiation of epidural anesthesia. Anesthesiology 1998;88:668–72.
0959-289X/$ - see front matter
c 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijoa.2010.08.005
Attenuation of the hypertensive response to tracheal intubation in patients with severe preeclampsia: a UK postal survey The 2005 CEMACH report identified two deaths in which intracranial haemorrhage was thought to have occurred as a result of the hypertensive response to tracheal intubation during induction of anaesthesia for emergency caesarean section.1 The report specifically recommended: ‘‘Anaesthetists should anticipate an additional rise in blood pressure at intubation in women with severe preeclampsia’’ and that ‘‘the anaesthetist should be given as much time as possible to try to prevent the presser effects of intubation’’. A recently published case series of 28 women in the USA supports the CEMACH report, suggesting that a systolic blood pressure of >160 mmHg in this patient group is associated with an increased risk of intracranial haemorrhage.2 There is little evidence on which to base a recommendation on a specific agent for use in this situation and no national guidelines currently exist. We undertook a national postal survey of all UK consultant obstetric anaesthetists, approved by the Obstetric Anaesthetists’ Association (OAA), to identify current practice in attenuating the hypertensive response. We defined severely hypertensive preeclamptic women as those requiring an intravenous infusion of an antihypertensive agent. We received replies from 479 consultants, a response rate of 44%. Only 34% of respondents worked in a department with a policy in place for pharmacological attenuation of the response to laryngoscopy and intubation. The majority (40%) of these were from departments with a workload of over 4000 deliveries per annum. In departments with a policy, 95% recommended alfentanil as the first line drug, with magnesium as the second most common choice. This was also reflected amongst anaesthetists’ personnel choice (Fig. 1).
Correspondence
Fig. 1 First choice drug for attenuation of the hypertensive response to tracheal intubation by number of anaesthetists/ departments.
Labetolol was a popular departmental alternative whereas individual anaesthetists cited remifentanil more frequently as their agent of choice. Despite published evidence of resultant morbidity and mortality, our survey revealed a lack of department guidelines for this scenario. A guideline provides a basis for all clinicians to work from and may be especially valuable in the emergency situation. Guidelines exist for other rare events such as malignant hyperthermia and are widely accepted as good practice. They are especially useful for more junior clinicians many of whom comprise the out-of-hours service within obstetric units. The survey highlighted an additional point of interest: only 34% of respondents would regularly use invasive arterial blood pressure monitoring in severely preeclamptic women undergoing caesarean section. The remaining 66% gave various reasons for non-use as standard: 43% considered it unnecessary whilst the remainder cited issues ranging from lack of equipment and level 2 critical care facilities to lack of midwifery training. There is no doubt that preeclamptic patients with significant hypertension are critically ill. They should be cared for in a suitable level 2 environment with appropriate provision of trained staff and routine availability of invasive blood pressure.3 This approach would negate the requirement for additional time to instigate invasive monitoring at caesarean section by allowing initiation when intravenous antihypertensive agents are started. Real-time monitoring is essential for successful titration of pharmacological agents in order to achieve the goal of preventing the hypertensive response to laryngoscopy. The appropriateness of invasive monitoring can be compared to other areas such as cardiac anaesthesia where it would be highly unusual to attempt laryngoscopy without direct measurement of arterial pressure. We also enquired about pharmacological attenuation of the response to extubation. Only 47% of responders
103 would consider using a pharmacological agent, the majority choosing a beta-blocker. As extubation is also highly stimulating and often provokes a hypertensive response, it is counter-intuitive to expend time and effort preventing the response to intubation if the corresponding response at extubation is ignored. This survey highlights some important issues in the management of severely preeclamptic patients with significant hypertension. Despite the low incidence of anaesthetic encounters with these patients it is vitally important that steps are taken to minimise the significant risk of morbidity and mortality that occurs during anaesthesia. The OAA are ideally positioned to lead on national guidance for the management of the severely preeclamptic women undergoing emergency caesarean section requiring general anaesthesia. We advocate the development of local and national guidelines to help standardise pharmacological treatment of women in this scenario and promote the provision of equipment, staff and facilities to allow invasive blood pressure monitoring as a standard of care. C.M.A. Booth, H. Buckley, S. Wheatly, S. Maguire Department of Anaesthesia, University Hospital of South Manchester Wythenshawe Hospital, Manchester, UK E-mail: [email protected]
References 1. Lewis G, editor. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer – 2003–2005. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH; 2007. 2. Martin Jr JN, Thigpen BD, Moore RC, Rose CH, Cushman J, May W. Stroke and pre-eclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Obstet Gynecol 2005;105: 246–54. 3. Comprehensive Critical Care. A review of adult critical care services.; 2000 [accessed 19.08.09]. 0959-289X/$ - see front matter
c 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijoa.2010.07.013
Transversus abdominis plane blocks; a national survey of techniques used by UK obstetric anaesthetists Women undergoing caesarean section are worried about intra- and postoperative pain.1 Good analgesia with minimal side effects is desirable if early mobility, bonding with the infant and prevention of chronic pain are to
Correspondence
it had been used, 155 (50%) would keep it on the same surface. This practice may increase the risk of contaminating the spinal equipment with disinfectant. Of the respondents, 357 (62.4%) always allowed the solution to dry before the procedure and a further 197 (34.4%) usually did. Failure to allow the solution to dry may also increase the risk of contamination of equipment. Use of an introducer needle may reduce the risk of spinal needle contamination. However, contamination is still theoretically possible, either from a retained core of skin within the introducer needle, or whilst the spinal needle is still on the sterile surface. Disinfectant need not be poured into the receptacle whilst it is on the same surface as the spinal equipment. Equally, spraying disinfectant directly onto the patients back enables distance to be kept from the spinal equipment and is equally effective.9,10 Whether pouring or spraying, multi-use containers could potentially become contaminated.11 Devices such as ChloraPrep resolve many of these issues but increase the production of waste and ChloraPrep only comes as 2% chlorhexidine gluconate in 70% isopropyl alcohol. Our survey demonstrates that there are still consultants using suboptimal disinfectants or not using them correctly. An even greater number of consultants are pouring the disinfectant into a receptacle on the same surface as the spinal equipment which may increase the risk of contaminating the equipment with disinfectant. Although the incidence of serious infective and neurotoxic complications remains small, the risks could be reduced by changing these practices. C.L. Bradbury, B. Hale, S. Mather, I. Suri Department of Anaesthetics, Warwick Hospital, Warwick, UK E-mail: [email protected]
References 1. Christie I. Infective meningitis. In: The Royal College of Anaesthetists. NAP 3: major complications of central neuraxial block in the United Kingdom. The Royal College of Anaesthetists; 2009: p. 71–5. 2. Pratt RJ, Pellowe CM, Wilson JA et al. Epic2: national evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 2007;65:S1–S59. 3. Hebl JR. The importance and implications of aseptic techniques during regional anesthesia. Reg Anesth Pain Med 2006;31:311–23. 4. Crowley L, Preston R, Wong A, Book L, Kuzeljevic B. What is the best skin disinfectant solution for labour epidural analgesia? A randomized prospective trial comparing ChloraPrep, DuraPrep, chlorhexidine 0.5% in 70% alcohol. Anesth Analg 2008;106:A3. 5. Cook TM, Fischer B, Bogod D et al. Re: antiseptic solutions for central neuraxial blockade – which concentration of chlorhexidine in alcohol should we use? Br J Anaesth 2009;103:456–7. 6. Fischer B, Damian M. Other nerve and spinal cord injury. In: The Royal College of Anaesthetists. NAP 3: major complications of
7. 8. 9.
10.
11.
central neuraxial block in the United Kingdom. The Royal College of Anaesthetists; 2009, p. 77–83. Angelique Sutcliffe v Aintree Hospitals NHS Trust, EWCA Civ 179, 2008. CareFusion. ChloraPrep (www.chloraprep.co.uk). Robins K, Wilson R, Watkins EJ, Columb MO, Lyons G. Chlorhexidine spray versus single use sachets for skin preparation before regional nerve blockade for elective caesarean section: an effectiveness, time and cost study. Int J Obstet Anesth 2005;14:189–92. Debreceni G, Meggyesi R, Mestyan G. Efficacy of spray disinfection with a 2-propanol and benzalkonium chloride containing solution before epidural catheter insertion – a prospective, randomized, clinical trial. Br J Anaesth 2007;98:131–5. Birnbach DJ, Stein DJ, Murray OMT, Thys DM, Sordillo EM. Povidine iodine and skin disinfection before initiation of epidural anesthesia. Anesthesiology 1998;88:668–72.
0959-289X/$ - see front matter
c 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijoa.2010.08.005
Attenuation of the hypertensive response to tracheal intubation in patients with severe preeclampsia: a UK postal survey The 2005 CEMACH report identified two deaths in which intracranial haemorrhage was thought to have occurred as a result of the hypertensive response to tracheal intubation during induction of anaesthesia for emergency caesarean section.1 The report specifically recommended: ‘‘Anaesthetists should anticipate an additional rise in blood pressure at intubation in women with severe preeclampsia’’ and that ‘‘the anaesthetist should be given as much time as possible to try to prevent the presser effects of intubation’’. A recently published case series of 28 women in the USA supports the CEMACH report, suggesting that a systolic blood pressure of >160 mmHg in this patient group is associated with an increased risk of intracranial haemorrhage.2 There is little evidence on which to base a recommendation on a specific agent for use in this situation and no national guidelines currently exist. We undertook a national postal survey of all UK consultant obstetric anaesthetists, approved by the Obstetric Anaesthetists’ Association (OAA), to identify current practice in attenuating the hypertensive response. We defined severely hypertensive preeclamptic women as those requiring an intravenous infusion of an antihypertensive agent. We received replies from 479 consultants, a response rate of 44%. Only 34% of respondents worked in a department with a policy in place for pharmacological attenuation of the response to laryngoscopy and intubation. The majority (40%) of these were from departments with a workload of over 4000 deliveries per annum. In departments with a policy, 95% recommended alfentanil as the first line drug, with magnesium as the second most common choice. This was also reflected amongst anaesthetists’ personnel choice (Fig. 1).
Correspondence
Fig. 1 First choice drug for attenuation of the hypertensive response to tracheal intubation by number of anaesthetists/ departments.
Labetolol was a popular departmental alternative whereas individual anaesthetists cited remifentanil more frequently as their agent of choice. Despite published evidence of resultant morbidity and mortality, our survey revealed a lack of department guidelines for this scenario. A guideline provides a basis for all clinicians to work from and may be especially valuable in the emergency situation. Guidelines exist for other rare events such as malignant hyperthermia and are widely accepted as good practice. They are especially useful for more junior clinicians many of whom comprise the out-of-hours service within obstetric units. The survey highlighted an additional point of interest: only 34% of respondents would regularly use invasive arterial blood pressure monitoring in severely preeclamptic women undergoing caesarean section. The remaining 66% gave various reasons for non-use as standard: 43% considered it unnecessary whilst the remainder cited issues ranging from lack of equipment and level 2 critical care facilities to lack of midwifery training. There is no doubt that preeclamptic patients with significant hypertension are critically ill. They should be cared for in a suitable level 2 environment with appropriate provision of trained staff and routine availability of invasive blood pressure.3 This approach would negate the requirement for additional time to instigate invasive monitoring at caesarean section by allowing initiation when intravenous antihypertensive agents are started. Real-time monitoring is essential for successful titration of pharmacological agents in order to achieve the goal of preventing the hypertensive response to laryngoscopy. The appropriateness of invasive monitoring can be compared to other areas such as cardiac anaesthesia where it would be highly unusual to attempt laryngoscopy without direct measurement of arterial pressure. We also enquired about pharmacological attenuation of the response to extubation. Only 47% of responders
103 would consider using a pharmacological agent, the majority choosing a beta-blocker. As extubation is also highly stimulating and often provokes a hypertensive response, it is counter-intuitive to expend time and effort preventing the response to intubation if the corresponding response at extubation is ignored. This survey highlights some important issues in the management of severely preeclamptic patients with significant hypertension. Despite the low incidence of anaesthetic encounters with these patients it is vitally important that steps are taken to minimise the significant risk of morbidity and mortality that occurs during anaesthesia. The OAA are ideally positioned to lead on national guidance for the management of the severely preeclamptic women undergoing emergency caesarean section requiring general anaesthesia. We advocate the development of local and national guidelines to help standardise pharmacological treatment of women in this scenario and promote the provision of equipment, staff and facilities to allow invasive blood pressure monitoring as a standard of care. C.M.A. Booth, H. Buckley, S. Wheatly, S. Maguire Department of Anaesthesia, University Hospital of South Manchester Wythenshawe Hospital, Manchester, UK E-mail: [email protected]
References 1. Lewis G, editor. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer – 2003–2005. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH; 2007. 2. Martin Jr JN, Thigpen BD, Moore RC, Rose CH, Cushman J, May W. Stroke and pre-eclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Obstet Gynecol 2005;105: 246–54. 3. Comprehensive Critical Care. A review of adult critical care services.
c 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijoa.2010.07.013
Transversus abdominis plane blocks; a national survey of techniques used by UK obstetric anaesthetists Women undergoing caesarean section are worried about intra- and postoperative pain.1 Good analgesia with minimal side effects is desirable if early mobility, bonding with the infant and prevention of chronic pain are to